<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_summary_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_summary_id" data-rule="required" data-source="presentation/summary/index" class="form-control selectpage form-control" name="row[presentation_summary_id]" type="text" value="{$row.presentation_summary_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Senders_diagnosis_event_meddra_code')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-senders_diagnosis_event_meddra_code" class="form-control form-control" name="row[senders_diagnosis_event_meddra_code]" type="text" value="{$row.senders_diagnosis_event_meddra_code}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Senders_diagnosis_repeat_as_necessary')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-senders_diagnosis_repeat_as_necessary" class="form-control form-control" name="row[senders_diagnosis_repeat_as_necessary]" type="number" value="{$row.senders_diagnosis_repeat_as_necessary}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
